Delayed and reversible ethambutol optic neuropathy.

Purpose: To document an unusual example of ethambutol optic neuropathy developing three years from treatment start date in the absence of renal dysfunction. Observations: The patient, an 82-year-old, 61-kg male undergoing treatment for Mycobacterium Avium Complex, presented with visual acuity that was significantly worse than baseline three years after beginning a treatment regimen which included ethambutol at <15 mg/kg/day. He was also found to have central and paracentral scotomas in both eyes. Ethambutol treatment was immediately halted, and the patient's visual acuity and visual fields improved in the months following. Conclusions and Importance: It is important to have a high index of suspicion for ethambutol toxicity in any patient on this drug who presents with vision changes consistent with optic neuropathy. The development of ethambutol optic neuropathy can be delayed, and vision loss may be reversible and can continue to improve over months after cessation of therapy.

Intracranial hypertension associated with topical tretinoin use.

PURPOSE: To report cross-reactivity between topical vitamin A derivatives and tetracycline-class antibiotics. OBSERVATIONS: A 19-year old woman with a remote history of resolved secondary intracranial hypertension due to minocycline use developed intracranial hypertension while using topical tretinoin alone. Examination demonstrated bilateral optic nerve edema, a right sixth cranial nerve palsy, along with characteristic features of markedly elevated intracranial pressure on imaging. Lumbar puncture opening pressure was 60 cmH2O. Cessation of topical tretinoin use ensued complete resolution of symptoms and optic nerve swelling in both eyes. CONCLUSIONS AND IMPORTANCE: Our findings substantiate the need to avoid topical vitamin A derivatives and alternate drug classes known to be associated with drug-induced intracranial hypertension.

Unilateral Isolated Paucisymptomatic Optic Disc Edema.

BACKGROUND: Unilateral isolated optic disc edema (UIODE) represents a challenging clinical presentation that frequently precipitates an extensive diagnostic work-up. Patients without an apparent diagnosis despite appropriate investigations are often categorized as having "papillophlebitis," an entity that is poorly defined in the existing literature. Our aim was to describe the characteristics of a series of patients with paucisymptomatic UIODE, determine the optimal diagnostic approach to such cases, and clarify the clinical features of presumed papillophlebitis. METHODS: We retrospectively identified 29 patients with UIODE who were seen by neuro-ophthalmologists at a single center between 2005 and 2019. Each patient presented with isolated, unilateral disc edema that was either entirely asymptomatic or associated with minimal visual symptoms. Patients underwent a comprehensive neuro-ophthalmic evaluation and several ophthalmic and systemic investigations. Data from the initial visit and all subsequent clinical visits were collected, including patient demographics, examination findings, and details of the diagnostic work-up. RESULTS: Our 29 patients with UIODE were found to have a variety of underlying diagnoses including unilateral papilledema due to idiopathic intracranial hypertension (10 patients), optic nerve sheath meningioma (5), incipient nonarteritic anterior ischemic neuropathy (4), vitreopapillary traction (3), orbital masses (2), a peripapillary choroidal neovascular membrane (1), and presumed papillophlebitis (4). The duration of disc edema varied considerably based on the etiology, but most patients had favorable visual outcomes. CONCLUSIONS: A systematic approach to the evaluation of UIODE, combined with long-term follow-up, led to a definite diagnosis in a majority of patients, with only 4 patients presumed to have papillophlebitis, a diagnosis the actual existence of which remains controversial.

A Pilot Study to Evaluate the Oral Microbiome and Dental Health in Primary Open-Angle Glaucoma.

PURPOSE: To evaluate possible associations between primary open-angle glaucoma (POAG), dental health, and the oral microbiome. METHODS: Case-control study was conducted at SUNY Downstate. Adult subjects (40 to 87 y) were recruited as POAG cases (n=119) and controls without glaucoma (n=78) based on visual field and optic nerve criteria. Overall 74.6% were African Americans (AA). Information on medical history and oral health was collected and ophthalmologic examinations were performed. Mouthwash specimens (28 AA cases and 17 controls) were analyzed for bacterial DNA amounts. Analyses were limited to AAs as the predominant racial group. Outcome measures included number of natural teeth, self-reported periodontal health parameters, and amounts and prevalence of oral bacterial species. Logistic regression was used to evaluate associated factors and potential interactions. RESULTS: Cases and controls had similar age (mean: 62.2 and 60.9 y, respectively, P>0.48), and frequency of hypertension, diabetes, but cases had a higher proportion of men (P<0.04). On average (±SD), cases had fewer natural teeth than controls [18.0 (±11.1) vs. 20.7 (±9.4)]. Having more natural teeth was inversely associated with POAG, in multivariable analyses, at older ages [eg, odds ratio (95% confidence interval) at age 55: 1.0 (0.95-1.06), P=0.98 vs. at age 85: 0.87 (0.79-0.96), P=0.007]. Amounts of Streptococci were higher in cases than controls (P<0.03) in samples from the subset of subjects analyzed. CONCLUSIONS: The number of teeth (an oral health indicator) and alterations in the amounts of oral bacteria may be associated with glaucoma pathology. Further investigation of the association between dental health and glaucoma is warranted.

Long-term outcomes in patients initially responsive to selective laser trabeculoplasty.

AIM: To determine the long-term effects of selective laser trabeculoplasty (SLT) on intraocular pressure (IOP) and the number of medications used up to 5y following treatment in glaucoma patients receiving maximally tolerated medical therapy (MTMT). METHODS: The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the charts of glaucoma patients who underwent SLT after receiving MTMT. Eyes that did not achieve their target pressure within 3mo following SLT were excluded from the study. Changes in mean IOP and number of glaucoma medications used were analyzed at 1, 3, and 5y following SLT. RESULTS: Seventy-five eyes of 67 patients were included in the study. Fifteen eyes that received SLT failed to achieve their target pressure within 3mo and were excluded from the study. The average follow-up time was 37.4mo (±14.4). Mean IOP was significantly reduced 1y after treatment (P=0.005). It was also reduced 3, 5y after treatment without reaching statistical significance (P=0.20 and P=0.072, respectively). There was a significant decrease in mean number of medications used 1, 3, 5y after treatment (P<0.001, P<0.001, and P=0.039, respectively). In the span of 5y, 2 eyes (2.7%) underwent repeat SLT, 7 eyes (9.3%) underwent glaucoma surgery and an additional 3 eyes (4.0%) underwent both. CONCLUSION: SLT significantly reduced the number of glaucoma medications used 5y following treatment in glaucoma patients receiving MTMT. SLT may delay operating-room surgery.